The start of the 2023 legislative session tomorrow isn't the only big news in Santa Fe this week. 

One of the most impactful financial and healthcare decisions will be made when the NM Human Services Department announces the companies that will be awarded contracts to run the state's Medicaid program for nearly 1 million lower income recipients--or almost half the state's population. And it won't be without some controversy. First, from HSD:

Managed care organizations work in partnership with the state’s Medicaid program and clinicians to provide access to physical and behavioral health, and long-term care services. Contracts with HSD’s current MCOs, Blue Cross Blue Shield of New Mexico, Presbyterian Health Plan, and Western Sky Community Care expire at the end of 2023. Beginning in 2024, the state’s Medicaid program, known as Centennial Care 2.0, will become Turquoise Care and will begin operation with the newly awarded MCOs. 

Western Sky Community Care is a subsidiary of Centene, the nation's largest Medicaid provider. It's taking heat over a $13.7 million fine it was hit with last year for overcharging NM Medicaid:

The nation’s largest private-care provider for Medicaid could be continuing its services in New Mexico, despite settling with the state for $13.7 million earlier this year over improper billing of prescription drugs. That is but a fraction of the $596 million in settlement payments Centene Corp. has made to 13 states because of questionable billing practices, so far.

The state Medicaid budget is now a towering $8.8 billion annually with two thirds of that covered by the Feds. 

Next door in Texas:

Centene has settled with Texas for $165 million to resolve claims of Medicaid fraud by the Texas attorney general. Centene made no admission of liability, and maintained that its business practices were lawful. Under the terms of the settlement, Centene will pay more than $165.6 million to resolve Attorney General Ken Paxton's investigation. . . The AG alleged that Centene overcharged Medicaid in the prescription drug program.  

THE POLITICAL SIDE

HSD says it will go by the book and award the Medicaid contracts under a scoring system and by the state procurement code. Still, Centene is a major political player, donating $30,000 to MLG's re-election effort and:

Since 2015, the St. Louis-based insurance behemoth, its subsidiaries, its top executives, and their spouses have given more than $26.9 million to state politicians in 33 states, to their political parties, and to nonprofit fundraising groups, according to a Kaiser Health News analysis of data from the nonpartisan group OpenSecrets. . .It’s a purposeful political investment: Centene earns billions of dollars from governments and then uses its profits to back the campaigns of the officials who oversee those government contracts. The company has developed this sophisticated, multipronged strategy as it pursues even more state government-funded contracts and defends against sweeping accusations that it overbilled many of those very governments. 

Of course, Centene is not alone among health care companies making political contributions and it has not been charged with any legal violations.

The company is a behemoth with deep experience, reporting $738 million in quarterly profit in last year's third quarter. Centene trades on NASDAQ as CNE and has a market value of over $40 billion. 

Their total national enrollment in Medicaid, Centene’s biggest business, is 15.7 million, up from about 14.8 million a year ago. 

Western Sky Community Care recently donated $3 million to help get the ABQ Gateway Center for the homeless up and running, 

Between FY19 and FY23, growth in state spending to provide Medicaid far exceeded growth in enrollment (56 percent versus 16 percent, respectively); yet, the healthcare that Medicaid enrollees actually used remained flat or declined over the same time, with a few exceptions. This is concerning as the significant health challenges experienced by the state’s Medicaid population will likely not improve if Medicaid enrollees cannot access the health care they need. The state’s inadequate healthcare provider network continues to be a significant barrier for Medicaid enrollees to access timely care. A Fall 2022 LFC secret shopper survey demonstrated these network shortages, with Medicaid enrollees only able to get an appointment with a primary care or behavioral health care provider 13 percent of the time.. . 

HSD says the contractors approved this week will have a long list of new standards to fulfill to improve Medicaid performance. 

What happens at the legislative session will have impact, but it's hard to top selection of the firms who will be trusted with the critical task of providing medical care for nearly half the state's citizens.

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